Provider Demographics
NPI:1699799932
Name:COLEMAN, WILLIE J JR (PHD)
Entity type:Individual
Prefix:DR
First Name:WILLIE
Middle Name:J
Last Name:COLEMAN
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2081
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:CT
Mailing Address - Zip Code:06420-2081
Mailing Address - Country:US
Mailing Address - Phone:860-405-0490
Mailing Address - Fax:860-449-9146
Practice Address - Street 1:481 GOLD STAR HWY
Practice Address - Street 2:SUITE 301
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-6224
Practice Address - Country:US
Practice Address - Phone:860-405-0490
Practice Address - Fax:860-885-0384
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000919103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004048088Medicaid
CT680001745Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER